We’re Jed Lipinski, a reporter for NOLA.com | The Times-Picayune, and Lee Zurik, a reporter for WVUE Fox 8 News.

For the past few months, we’ve been writing about the cost of health care in Greater New Orleans as part of our “Cracking the Code” series. With help from ClearHealthCosts, a New York-based journalism start-up, we’ve exposed how the cost of common medical procedures varies dramatically depending on your provider or health insurance.

Through our reporting, we learned that the cost of most medical procedures is intentionally hidden from the public. As a result, most patients have no idea what they will pay prior to visiting the emergency room or undergoing an operation. This directly benefits insurance companies and health care providers, whose prices often have no relationship to the cost of the service itself. Overcharging is the norm.

Our goal throughout has been to enable consumers to make educated cost decisions about their health, the same way they can about food at the grocery store or fuel at the gas station.

Are prices are fudged depending on the number of unprofitable services that the hospital provides? For instance if a hospital needs to pay for a lot of elderly folks or medicaid folks or people that simply don't pay their bills, the hospital would want to charge more for other procedures. Is this a large factor in the price discrepancy?

Jed: Great question. It's something we addressed in a May story about facility fees, where a clinic affiliated with a hospital charges an extra fee for the "facility" -- as if medical procedures would take place anywhere other than a facility. (Outside?) In this story, a woman was hit with a $137 facility fee because the sports medicine clinic she went to was affiliated with Tulane Medical Center across town. Tulane Medical Center has a busy 24-hour ER that takes in a lot of people who can't afford to pay. So they (and other hospitals in similar situations) will try to justify charging extra fees, like a "facility fee," because they lose money by providing services that small clinics without pricey ERs don't have to bother with.

As we wrote in the story: "Federal law allows hospitals to charge facility fees for outpatient services at affiliated clinics, regardless of whether the clinic is anywhere near the hospital. The clinics may have the same equipment, staffing and operating expenses as a private practice, and may look much the same as a private practice, but the simple fact that they're connected to a hospital entitles them to charge that extra fee."

Thanks for your response! So how much would you attribute varying fees to simply shuffling money around to cover bills? Because if its 100%, then you essentially have a zero-sum game and there is no solution that doesn't involve pinching the ERs. Although you could expect some efficiency improvements to result from patients shopping around, people will never shop around for ERs. So how much would the practice of shopping around for basic healthcare hurt the finances of ERs?

Jed: Another good question. Big hospitals like Tulane are certainly doing a form of public service by treating patients that they know are unable to pay. How else would they get treatment? But does that mean that patients who go in for a shoulder exam at an affiliated clinic should be picking up the bill for the ER? It's ultimately the responsibility of the state and federal government to ensure that hospitals like Tulane have enough money to keep their ERs open. The absurdity of the current situation is evident in the fact that facility fees are often higher than the actual doctor's fee.

Two things: People who tend to overuse the ER may have been failed multiple times by the health care system -- preventive health in this country does not work; people who lack insurance may go to the ER because they have nowhere else to go; and basically we don't think the ER is the source of the problem.

We also don't think that cost-shifting is really at the root of the problem. Here's another way to think about it, mentioned elsewhere here: a chart that shows the growth of non-physician employment in health care; that seems to us to be a much larger factor.

Have you spent any time in an ER observing the types of cases which walk in the door? I volunteer in EMS and my guess is that about 3/4 of people don't need to go to the ER in the first place and could be seen for a fixed-price at a walk-in clinic.

You might be right. We don't have that information. We're interested in knowing more about your experiences.

What we do know: People don't understand that walking in the door at an ER could guarantee a terrifying bill. Often people believe that 1) it's covered, whatever that means, or 2) prices are somehow uniform or 3) prices are somehow regulated. They tend to be shocked when they get ER bills, because none of these three things are uniformly true.

If you wish, reach out to us at (address of your choosing? we'd be happy to talk at [email protected]

I think it's up to consumers and journalists. Transparency will help change everything. Right now, when you go to get a procedure, you likely have no idea of the cost until you pay the bill. And you don't know the cost of the same procedure down the street or nearby. Price transparency will change that. But consumers also need to start asking questions. Shop around. Ask your cost before you get the procedure. It takes time, but can save you money. - Lee Zurik

I have a big problem with shopping around for health care. Heath care is nothing like buying a shiny doodad. You can live without doodads but your health is very important. Which means you tend to form relationships with providers you trust. Shopping around means going with someone else and perhaps away from the recommended specialists of your primary provider. Also, as severity and emergency of a health situation increase so do the costs as well as the time in which to deal with it.

A lot of times even with insurance and especially with the emergence of high deductible plans, you get hit with things after the fact. My oldest son recently had a short procedure (which would have been somewhere in the neighborhood of $10k USD, if you believe the prices) and the provider was very concerned about my high deductible but didn't bother to go over anything else with me. This was the second time he had the procedure (tubes in ears) at the same location, but this time one small portion of procedure was out-of-network. So even though we had met our in-network we got hit with another bill. I didn't think to ask about it because, one my mind was on my child and two I had gone through this without the additional out-of-network expense the previous year.

There are simply so many moving and shifting parts to the whole machine that getting an up front price is going to be impractical at best.

What do you think it'll really take to bring more transparency to medical costs (or health insurance in general)? Is it government action or startups trying to disrupt the industry? Thanks for your work!

I think it's journalists and consumers. Government hasn't brought transparency to healthcare pricing and it's not likely to change. It will take journalists doing projects like we did. Our partner Clear Health Costs is a great example of a group trying to disrupt the healthcare market by shining a light on prices. And it's also up to consumers to start asking. - Lee Zurik

I went into an ER for a simple x-ray a few years ago. I asked the lady at the front for a cost estimate 3 times, she kept saying I can't give you that and only that 'we wont turn away anyone based on their ability to pay'. Lakeview Regional in Covington, LA for anyone interested.

I went ahead and did the x-ray, got stuck with a $750 bill for something that took 15 minutes. It was the only bill in my life I refused to pay. Now that expense gets passed on to the next person unfortunately.

We really need a healthcare.gov for medical procedures and mandate that providers list and honor the price shown, but for now they just continue to guard their prices like Coke's secret formula.

Jed: Sorry to hear that. In the future, you can try shopping for a better price through the database people from the community (and some cooperative health care providers) helped us build. In many cases, as we've noted in a number of stories, procedures can be had for less -- and sometimes much less -- if you agree to pay cash up front. The trick is: You need to ask about a cash price ahead of time. http://www.nola.com/health/index.ssf/2017/04/new_orleans_pricecheck.html

Thanks. And thanks for telling us your story. We found that some providers are willing to share prices...but many are still not. It can take a lot of time to price a procedure. And it can be frustrating. - Lee Zurik

How can you report a hospital for Medicaid fraud when it's the only hospital in town?

I live in the Alaskan bush and we have blatant insurance fraud going on (double billing, simple procedures billed as higher priced procedures etc) and we only have one hospital. The majority of the population here is on IHS, basically Medicaid for native Alaskans.

Is there anything we can do without the only hospital within 350 miles shutting down? Otherwise we have to pay to go to Anchorage for anything non life threatening and that's nearly 1k for one person.

From Jeanne Pinder:
We'd like to hear more. We work across the nation, and we have a particular interest in Alaska because of the well-known issues there with price and accessibility. If you want to get in touch outside of Reddit, we would welcome that! email [email protected].

Jed: Good one. Having just gone through a months-long project about health care pricing, I can say an excellent way to find tipsters and sources is to do what we did: Publish a few stories about the drastic disparities in health care costs in your region. It's an enormous problem that most people are reluctant/embarrassed/ashamed to talk about, but once you start airing it in public, people rush to tell their story. For weeks, we received dozens of emails and voice messages per day from a wide variety of people -- including MDs and former health insurance employees -- who often spoke to us on the condition of anonymity but pointed us in the right direction. It took gathering some eye catching data -- A $522 blood test could be had for $19 across the street? -- to get the ball rolling.

I think it all starts with price transparency. When you go buy a TV or a car, you know the price going in. You can compare prices from different stores. In healthcare, the prices are typically hidden. You don't know the cost going in. It allows providers to charge what they want, instead of what the market wants. - Lee Zurik

I agree with that, but dont you think another issue that causes the broken price structure is the bureaucracy and red tape? Unnecessary paper-pushing tacks on alot of extra cost, and as a result some of those costs can't be as transparent.

Germany has a combination of mandatory, essentially public, insurance, which covers most people, and also optional private insurance for people who can afford it.

They also have one other big difference in their health care system: fewer for-profit entities.

I am all for free enterprise, but in health care it doesn't work that well: a for-profit insurance company or hospital is answering to its stockholders, and that necessitates tradeoffs. For-profit Big Pharma is looking for, well, profits. See Epi-Pen.

there are people called "medical billing advocates" and similar --they work on contingency or flat-fee, and promise to save you money. we don't know much about them and because of this, we do not recommend any. if you find a good one or ones, please let us know! and thanks!

Jed: Well thanks. And good question. I think they came partly from our partnership with ClearHealthCosts, whose team did the tedious and frustrating but crusading work of reaching out to every major health provider and clinic in the greater NOLA area and asking for the cash prices of their most common procedures. They then helped us create an online database to store the data they received, so we could begin writing stories off that data, which elicited more data from consumers, etc. It's a magical formula for journalism, and a great way to take the powers that be by surprise.

Speaking to your point about consumers asking questions: my GP sent me to a dermatologist to have a small cyst removed. I spoke with the office beforehand and said that I do not wish to have it tested, it is just a fatty cyst and they said ok. When I got the bill it was $1,000 and a big part of that was the testing I asked them to leave out. When I went to question this they said that is standard policy and made me go on a payment plan to pay the bill. In an instance like this, does the consumer have any path of recourse? I felt like I didn't.

Jeanne Pinder of ClearHealthCosts points out that on their home site, they also have data for San Francisco, Los Angeles, Philadelphia, New York , Miami and Tampa-St. Petersburg. Just go to their site and search. You can also share your prices (click on button at top right of home page).

And also note some general principles; In San Francisco, for example, a simple MRI can cost $450 or $6,221. In New York, the range is $350-$2,783. So broad variations in prices are the rule, not the exception--not just for this procedure, but for pretty much all procedures.

I think our investigations have had a lasting impact on many of our viewers and readers. Many have told us they've learned some valuable lessons. Some have told us stories about saving money. - Lee Zurik

We are not suggesting that there should be price-fixing. On the contrary, we think people should be able to charge whatever they want. But they should tell people up front.

As it stands now, you don't find out in many cases until much much later that you are being charged a hefty price. We think the reason for the difference in pricing is simply that they can: Since prices are opaque, there's total information asymmetry.

And you can bet that wherever there's information asymmetry, people are making money.

It isn't necessarily that prices are opaque. The doctor's office can tell me what they charge for X, but then I need to contact my insurance company to see how much of X they will cover. Or I can ask the doctor's office to do that for me. It's the levels of coverage that create discrepancies.

The prices aren't a secret - you just have to ask for them.

I am fully supportive of what you folks are doing, but fundamentally it appears that you are asking hospital to operate like non-profits. But why should a for-profit institution be expected to do so?

Are you ultimately advocating for the de-privatization of health care?

From Jeanne Pinder:
We're glad you have had such success in getting prices. Not all are so persistent and fortunate!
What the woman who saved nearly $4,000 found was that if she chose a different provider, the cost went from $4,458 to $672.68.
https://clearhealthcosts.com/blog/2017/05/saved-3800-mri-people-use-data/
She didn't know there were such price discrepancies, but we are certain that the next time she will ask.
And no, what we're doing has no relation to non-profit or for-profit status. Everybody should be able to choose how they want to organize their business --- for-profit, nonprofit, LLC, C Corp, mom and pop shop.
We just think they should reveal the prices. All the prices. All the time.

Jed: We spoke about this with a patient engagement advocate and cancer survivor named Dave DeBronkart, also known as ePatient Dave. He noted that keeping prices a secret isn't just bad for patients, it's also bad for businesses. If the market is being run by secret deals and prices are hidden from public view, it's hard for clinics and hospitals that do a good job to be rewarded in the marketplace.